(Rev 7/06)
* If the applicant is a corporation partnership or LLC list all persons with 10% or more ownership interest below
Applicant must sign this form
APPLICATION FOR
CIGARETTE WHOLESALE DEALER AND/OR
Cigarette Wholesale Dealer D
Form CT 5
If the applicant is a corporation partnership or LLC list principal owners (ownership interest of 10% or more)
Location of Accounting Records Street or Road (NO PO BOX) City State Zip Code
MAIL THIS APPLICATION TO: VERMONT DEPARTMENT OF TAXES 133 STATE STREET MONTPELIER VT 05633 1401
Mailing Address Street Road or PO Box City State Zip Code
Name of Applicant* Telephone Number Federal ID Number
Name of Contact Person E mail address Telephone Number
Physical Location of Business Street (NO PO BOX) City State
Please print or type Incomplete and/or illegible applications will be returned
Principal owner name Address City State ZIP Code
Principal owner name Address City State ZIP Code
Principal owner name Address City State ZIP Code
Principal owner name Address City State ZIP Code
Principal owner name Address City State ZIP Code
Printed Name Title
Reason for Application
Signature of Applicant Date
TOBACCO DISTRIBUTOR LICENSE
Tobacco Wholesale Distributor
Trade Name of Business
VERMONT DEPARTMENT OF TAXES
